From The Floor

Ebola in America: What We Learned

The outbreaks, the hysteria and the science

Mere mention of the word “Ebola” has long struck fear in the hearts of mankind. After years of nervous jokes in the West, the arrival of the first documented cases of Ebola in the U.S. has provoked a veritable panic. Naturally, nurses have been on the front lines and have been some of the first victims. But that doesn’t mean we should let fear to outweigh the facts.

WHAT IS EBOLA?

Named for the Ebola River in the Democratic Republic of Congo, Ebola is a member of the Filoviridae family of viruses and one of five known viral hemorrhagic diseases. It was first identified in 1976 after an outbreak of the same strain that is causing so much consternation today. Scientists still aren’t sure of the vector, although current theories point to fruit bats, which are sometimes consumed in the rural West African villages where outbreaks have started.

Ebola is contagious, although it isn’t as easy to contract as the flu or the common cold. Ebola is spread primarily through direct contact with the bodily fluids of an infected person, although it can also be contracted if uninfected people touch their eyes, nose or mouth after skin-to-skin contact with an infected person.

There is no indication that Ebola is airborne, although scientists have suggested it could be transmitted via the small droplets in a sneeze or other secretions. Luckily, the virus itself is rather easy to kill. Contaminated clothes or objects can even be disinfected with household bleach.

People infected are contagious as soon as they have symptoms. In some outlier cases, the incubation period may be as long as 42 days, but symptoms generally appear three to 21 days after infection, which is why current protocols specify a 21-day monitoring/quarantine period.

Like so many other illnesses, Ebola first presents with flu-like symptoms such as fever, muscle aches and so on. These are soon followed by vomiting, diarrhea, and external and internal bleeding that can lead to organ failure and death. One of the reasons the disease is so frightening is that the mortality rate for some strains can be as high as 83 percent. Ebola is classified as a P-4 (biosafety level 4) virus.

CURRENT OUTBREAK

Because Ebola is so lethal, past epidemics have burned out quickly and rarely moved beyond the rural villages where they began. However, the current outbreak has spread into more urban areas of the West African nations of Senegal, Nigeria, Mali, Sierra Leone, Guinea and Liberia, with the latter three hit the hardest. (This might be a good time to remind readers that Africa is not a country, but a huge continent of 47 different nations — a point some in the media seem to miss.)

The CDC estimates that as of Oct. 31, 2014, Ebola has infected a total of 13,540 people and killed 4,941. According to the World Health Organization, only 2,387 cases and 1,590 deaths occurred between 1976 and 2012, so the present outbreak is the worst on record.

This is also the first time Ebola has arrived in Europe and the United States. Most of the cases diagnosed in Europe to date have involved aid workers or healthcare providers who treated victims of the outbreak in West Africa. The first diagnosed case in the U.S. was a Liberian visitor named Thomas Eric Duncan, who traveled to Dallas to visit his fiancée and her family.

As has been exhaustively covered by the news media, Duncan was admitted to the ER at Texas Health Presbyterian Hospital, discharged and then readmitted three days later, at which point he was diagnosed. He died on October 8.

THE BLAME GAME

The Duncan case prompted a flurry of finger-pointing about the hospital’s response, particularly after two of the nurses involved in his care, Nina Pham and Amber Vinson, tested positive for Ebola. There were cries of indignation throughout the nursing blogosphere when CDC Director Thomas Frieden, M.D., MPH, attributed the infection of the two nurses to a “protocol breach.” (He later apologized.)

On October 15, National Nurses United issued a statement from unidentified nurses at Texas Health Presbyterian alleging that the hospital failed to provide the staff with clear protocols, proper safety equipment or training, putting nurses and other patients at risk. The hospital has denied those allegations, saying they “do not align with facts stated in the medical record and the accounts of caregivers who were present.” (Pham has said publicly that she did indeed receive personal protective equipment.)

Compounding the controversy was the fact that Vinson traveled from Dallas to Cleveland on a commercial airline flight after she developed symptoms and thus was potentially contagious. She says a CDC official cleared her to fly because she was still below the 100.4-degree fever threshold, but her actions were then publicly criticized by Frieden. The plane on which she’d flown was grounded for decontamination while officials tracked down and tested every other passenger on the flight.

Both Vinson and Pham have now been declared Ebola-free, as has Pham’s dog, who was monitored closely to ensure he was also free of the disease. (He was lucky; the Spanish government preemptively euthanized a dog owned by a healthcare worker who had tested positive for Ebola in Madrid.)

Nonetheless, debate continues over the appropriate response to possible exposure. Several states — including California — now require a 21-day quarantine for medical personnel or travelers who have visited an affected area and had contact with Ebola victims. (You can see the order from California’s state health officer.)

Some argue that quarantine is a worthwhile precaution, but mandatory quarantines in other states have already provoked at least one court battle and CDC Director Frieden warns that measures that stigmatize healthcare providers or aid workers may do more harm than good.

THE PROGNOSIS

There is still no cure for Ebola, although there are experimental treatments such as ZMapp, a composite serum of three monoclonal antibodies. However, aggressive supportive care is still the gold standard for treatment. Of course, the patient’s overall health and factors such as age and nutrition also have a significant impact on the chances of survival.

The disease can be successfully treated even without experimental drugs or high-tech equipment. CNN reported the remarkable story of Fatu Kekula, a nursing student in Kakata, Liberia, who improvised her own protocols to care for four infected family members and managed to save three of them. (Kekula’s nursing instructors should be very proud!)

People who survive are generally safe from re-infection for 10 years or more. Convalescent serum created from their blood may also help other victims, a theory first outlined in a 1999 article in the Journal of Infectious Disease. However, the WHO says that while convalescent serum doesn’t hurt, there’s not yet enough data to know how effective it really is.

FROM FEAR TO HOPE

Ebola is scary. It’s far deadlier than past medical preoccupations like swine flu and, like most epidemics, it’s pointed out that our government, healthcare leaders and hospitals weren’t as well prepared as they claimed to be. However, earlier errors are being rapidly analyzed to create better protocols.

The most encouraging news is that both Senegal and Nigeria were recently declared Ebola-free — meaning they’ve gone more than 42 days without any new cases or symptoms — without resorting to any of the extreme measures some Western alarmists have proposed, such as closing borders or euthanizing sufferers.

In both countries, public health officials responded quickly, established clear protocols for testing and monitoring, made sure providers were properly trained and worked hard to prevent misinformation and panic. Nigeria, which has a population of more than 170 million, is a much poorer country than the U.S. and had more than twice as many diagnosed cases of Ebola, so we could take a lesson from their experience.

Above all, we must not let our fear paralyze us. Panic doesn’t contain outbreaks and neither does grandstanding. Let’s shift our focus back to the quality care nurses can deliver. That’s what will make a difference, whether with Ebola or the next deadly disease to come along.

Geneviève M. Clavreul RN, Ph.D., is a healthcare management consultant who has experience as a DON and as a lecturer on hospital and nursing management.

Photo above: Declared “Ebola-free” after treatment at the National Institute of Health, Nina Pham, RN, CCRN, embraces Anthony Fauci, M.D., director of the National Institute of Allergy and Infectious Diseases. He called her a “courageous and lovely person.”

Nurses at the Epicenter

Teresa Romero Ramos

One of the first people outside West Africa to contract Ebola was this nursing assistant at Carlos III Hospital in Madrid, Spain. Romero Ramos says she tried repeatedly to seek help after symptoms began, but was turned away three times and not properly isolated until testing confirmed what she already feared. She recovered and is now Ebola-free, but sadly, her beloved dog Excalibur was put down at government order despite widespread protests.

Nina Pham, RN, CCRN

Part of Thomas Eric Duncan’s care team at Texas Health Presbyterian in Dallas, this Vietnamese-American nurse from Fort Worth was the first to contract Ebola on American soil despite her protective gear. She was treated at the National Institutes of Health Clinical Center in Bethesda, Md., and is now free of the disease. Unlike poor Excalibur, Pham’s beloved dog Bentley was monitored but not harmed by Fort Worth health officials, who even sent Pham a video to reassure her that Bentley was okay.

Amber Vinson, RN

Another Texas Health Presbyterian nurse to test positive for Ebola after treating Thomas Eric Duncan, Vinson presented with symptoms while in Cleveland planning for her upcoming wedding. She sparked a national controversy by flying back to Dallas, although she says the CDC gave her the okay to fly. After she tested positive, the CDC scrambled to have the plane decontaminated and track down everyone with whom she may have had contact. Vinson was treated at Atlanta’s Emory University and declared free of the disease.

Fatu Kekula

After her Ebola-infected father was turned away from several Liberian hospitals, this heroic 22-year-old nursing student treated him and three other infected family members in their home in Kakata. With only telephone advice from a local doctor, she established her own quarantine procedures, set up IVs and created homemade hazmat suits using plastic garbage bags. Her young cousin died of his illness, but Kekula’s scrupulous adherence to her improvised protocols protected her from infection and enabled her to save both her parents and her sister.

Kaci Hickox, RN, BSN, MPH

This American nurse returned from treating Ebola patients in Sierra Leone for Doctors Without Borders only to find herself detained at the Newark Airport. She was confined to a plastic isolation tent at the order of New Jersey Gov. Chris Christie despite having tested negative for Ebola. Threats of civil rights litigation enabled her to return home to Fort Kent, Maine, where she ended up going to court to successfully challenge yet another quarantine order. Hickox agreed to keep a low profile until officially declared Ebola-free, but maintained that her forced isolation “was not supported by science.”